Document rxveaBZ8dwDd44NojdJxzMGRG

o 00 CCMM o o csi ui <H wX <o Xh-1 < < z aM zo l--l io-J cX H CJ < 03 X Z hi X HXo os z uw H --< 03 X H03 u XX o 3 CM 0vO0 \0 cn o> n CM S 3 H i--i X C/3 >< HXo<s Q XM H* Z O 2 o a. o0u2 WC/3 J< C/3 w 1-1 )1--1( z> 0z3 Xo '-) C/3 > az< oXJ 3 X X w 0o3 WORKERS' COMPENSATION CLAIM o z M OS [d <td H 3S < Z oOJS Co as Hos zo w H |CSO CN 00r-4 vD cn oCnN OS U3 2M 3 a A Form M-03 DUKE UNIVERSITY MEDICAL CENTER MEDICAL NOTE HOLLAND, Joseph N7 7 630 Dr. Saltzman MPDC 7/29/80 The patient is a 50-year-old man who has worked for a.-number of years for Babcock and Wilcox. In the course of this work, between 1952 and 1970 he was exposed to asbestos fibers. The exposure was perhaps heavier and was associated with the onset of relevant symptomatology between 1965 and 1970. I note that his involvement was associated with boiler manufacturer and testing. The patient has been referred by the Travelers Insurance Co. and the Industrial Commission for a further assessment of this problem and for an appropriate quantitative judgement as to the extent of impairment. CHIEF COMPLAINT: Asbestosis. HISTORY: During the past five years the patient has been aware of progressive breathlessness. At this point in time he can walk without dyspnea, at a slow pace, on'level ground. Exercise of greater magnitude will'induce acute dypsnea. He does not have orthopnea. The patient is bothered by a chronic cough productive of sputum, particularly in the morning. The sputum may.be brown or green. He breathes more easily after expectorating sputum in the morning. There is an approximate 30-35 pack year cigarette smoking history. He did terminate cigarette smoking approximately five years ago. The review of systems otherwise was positive for swelling of the hands with physical activity. The past medical history othenri.se was positive for the usual childhood illnesses, an appendectomy and tonsillectomy. The family history was positive for hypertension and cardiovascular disease. . Physical examination revealed a well developed white man. Vital signsrweight 200; height 5*8 1/2"; BP 118/82; respirations 16; pulse 74. Skin: no acute eruptions. Head, Neck: benign fundi, normal ocular motion, no acute inflammation of mucous membranes, adequate nasal passages, supple neck withotCmasses. Thorax: symmetrical, adequate excursions. Normal resonance. Persistent inspiratory subcrepitant (velcro) rales at.both bases. Cardiovascular: regular rhythm, no murmurs. No edema. Intact peripheral pulses. Breasts: no masses. Abdomen: no masses. External genitalia: normal to inspection and palpation. Rectal: good, sphincter tone, normal sized prostate gland. Chemical test of stool negative for occult blood. Extremities: no gross deformity Neurologic: intact. Assessment: 1) asbestosis.* 2) history of cigarette abuse - 1 c . 3) increased body weight 4) swelling of hands-cause not clear. Recommended management: 1) data base to be expanded with complete blood count, urinalysis, 14 blood chemistries, ECG, chest x-ray, pulmonary function tests, cardiorespiratory stress test and a A Form M-03 DUKE UNIVERSITY MEDICAL CENTER 2- - HOLLAND, Joseph N7 7 630 Dr. Saltzman MPDC 7/29/80 cytologic examination of a fresh a.m. sputum. I will review the results of these tests and prepare an appropriate assessment with a quantitative estimate of impairment. 2) my office will write to Mr. Misenheimer and request that previous x-rays be forwarded for comparison. An information release form has been signed. , Herbert A. Saltzman, M. D. HAS/cm D: 7/29/80 T: 7/29/80 cc: Patient Travelers Insurance Go. 4 * Urine: yellow and clear in appearance; pH 5.0; specific gravity 1.024; neg. protein; neg. sugar; rare WBC; neg.`RBC; rare epithelial cells; ne,g. bacteria; neg. casts; neg. ketone bodies; neg. benzidine; bilirubin 1+; Ictotest neg. CBC: hemoglobin 15.3 gms.%; hematocrit 45.5%; RBC 5.54; WBC 7,500; 61 neutrophils; 30 lymphs; 9 monocytes; 1+ microcytosis; adfequate number of platelets. MCV 80; MCHC 33.8. Chem 2:sugar 125; BUN 20 Chem 12: total protein 7.3; albumin 4.1; calcium 9.1; phosphorus 2.9; cholesterol 189; uric acid 7.5; creatinine 1.0; total bilirubin 0.7L alkaline phosphatase 128; LDH 216; SGOT 29. JBKG: normal sinus rhythm, rate 61; normal ECG; no comparison will be performed because no valid previous ECGs were found. Chest x-ray: PA and lateral views of the chest show a slight interstitial component in the right lower lung field laterally and a moderate interstitial component in the left lower lung field. No definite alveolar process can be seen. Localized areas of pleural thickening are seen in both chest cavities. This is much more marked on the left than on the right. The heart and mediastinum are within normal limits. The findings as noted on these films would be consistent with clinical impression of asbestosis. - Sputum: Cellular changes consistent with squamous metaplasia. f ' Form M-03 DUKE UNIVERSITY MEDICAL CENTER ADDENDUM- HOLLAND, Joseph N7 7 630 Dr. Saltzman MPDC 8/12/80 The test results are now available for review. The history of exposure, physical findings of subcrepitant basal inspiratory rales, the pulmonary function tests and chest x-ray picture all provide strong support for the diagnosis of ' asbestosis. Pulmonary function tests (attached) reveal moderate restriction and mild obstruction.7*5Cardiorespiratory stress test revealed a maximum oxygen uptake less than predicted normal (70% of predicted value). This calculation is based on body weight. Recalculation of appropriate parameters, based on an ideal body weight, revealed an oxygen uptake in the normal range (87%). At his maximum effort, however, the patient was limited by impaired ventilation and gas exchange,' his minute ventilation was 84% of the maximal voluntary ventilation and under the same conditions of maximal work a drop in arterial blood oxygen tension occurred (mild). Baseline resting arterial blood gases were 92 and 40 mmHg respectively for Pa02 and PaC02 (normal). At the maximal level of exercise the Pa02 was 83 and PaC02 was 38 mmHg. 4 A The functional capability of the patient, as described by him, and the objective test results place him at the interface between Class II and Class III AMA impairment (respiratory). I interpret his whole body impairment to be approximately 40%. This impairment is attributed to asbestosis. The level of airway obstruction detected on testing is mild, and could reflect either the effects of asbestosis or o| chromic bronchitis incurred from cigarette smoking. There is no evidence of the latter contributes to any substantial degree to overall impairment at this time. The increased body weight is an aggravating factor, reducing the patient's overall level of functional capability significantly. Recommendations: 1) this patient will need long term medical follow-up and supervision. His best health interest would be served by weight reduction to an approximate ideal level of less than 160 pounds. The past history of cigarette smoking and asbestosis exposure place him in the increased risk group in terms of malignant illness. Chest x-rays and medical check-ups should be performed at six month intervals.. HAS/cm D: 8/12/80 T: 8/12/80 cc: Patient Travelers Insurance Co. ______________ Herbert A. Saltzman, M. D.